This invention relates generally to the use of radiation therapy equipment for the treatment of tumors, or the like, and specifically to a method for modifying a prepared radiation treatment plan in response to a detected change in a tumor, or the like.
Medical equipment for radiation therapy treats tumorous tissue with high energy radiation. The amount of radiation and its placement must be accurately controlled to ensure both that the tumor receives sufficient radiation to be destroyed, and that the damage to the surrounding and adjacent non-tumorous tissue is minimized.
In external beam radiation therapy, a radiation source external to the patient treats internal tumors. The external source is normally collimated to direct a beam only to the tumorous site. The source of high energy radiation may be x-rays, or electrons from linear accelerators in the range of 2-25 MeV, or gamma rays from highly focused radioisotopes such as a Co.sup.60 source having an energy of 1.25 MeV.
Typically the tumor will be treated from several different angles with the intensity and shape of the beam adjusted appropriately. The purpose of using multiple beams, which converge on the site of the tumor, is to reduce the dose to areas of surrounding non-tumorous tissue. The angles at which the tumor is irradiated are selected to avoid angles which would result in irradiation of particularly sensitive structures near the tumor site. The angles and intensities of the beams for a particular tumor form a treatment plan for that tumor.
One highly accurate method of controlling the dose to a patient employs a radiation source that produces a fan beam composed of many individual rays whose intensity may be independently controlled. The fan beam orbits the patient within a plane illuminating a slice of the patient, while the intensity of each ray of the fan beam is modulated as a function of that angle. By properly selecting the beam intensities at different angles, complex regions within the slice may be accurately irradiated. U.S. Pat. No. 5,317,616, issued May 31, 1994, describes the construction of one such machine and one method of calculating the necessary beam intensities as a function of angle.
In order to take advantage of the improved accuracy in dose placement offered by such radiation therapy systems, the radiation treatment plan may be based on a computed tomography (xe2x80x9cCTxe2x80x9d) image of the patient. As is known in the art, a CT image is produced by a mathematical reconstruction of many projection images obtained at different angles about the patient. In a typical fan beam CT acquisition, the projections are one-dimensional line images indicating the attenuation of the fan beam by a xe2x80x9cslicexe2x80x9d of the patient. After reconstruction of the two-dimensional tomographic image of the slice, the projection data, which by itself is unintelligible, is no longer used or accessed by the user.
Using the CT image, the radiologist views the tumorous area and determines the beam angles and intensities (identified with respect to the tumor image) which will be used to treat the tumor. In an automated system, such as that described in U.S. Pat. No. 5,317,616 issued to Swerdloff, and incorporated herein by reference, a computer program selects the beam angles and intensities after the physician identifies the tumorous region and nearby sensitive structures, and upper and lower dose limits for the treatment. The region of interest is represented by a 3-D array of voxels, as is known in the art.
Normally, the CT image of the patient is acquired substantially before the radiation treatment to allow time for the treatment plan to be prepared. As a result, the tumor or sensitive structures may have grown or otherwise deformed to a shape different from that when the CT image was first acquired. This may also be true in cases where the treatment occurs during a number of different treatment sessions over time.
The present invention provides a system and method for adjusting the original optimized intensity to address over or under dosage caused by growth, deformation or other changes in shape or position of a tumor or diseased tissue between the time of a planning CT image and radiotherapy. Generally, this is done by determining a dose for an image acquired just prior to radiation treatment, and comparing this dose distribution with the planned dose distribution to ascertain which voxels need a dosage adjustment.
In the rotational radiotherapy delivery system with which the present system and method are preferably employed, a series of steps are normally undertaken to deliver complete patient treatment. Those steps are:
1. image input;
2. planning;
3. optimized treatment planning;
4. patient positioning/registration;
5. delivery modification;
6. delivery;
7. delivery verification;
8. dose reconstruction; and
9. deformable dose registration.
The image input step consists of a clinician taking images of a patient, for example CT or MRI images, to establish a region of interest (e.g., a tumor and possibly a portion of the surrounding tissue) and regions at risk (i.e., sensitive organs or structures).
The planning step consists of a clinician formally designating the regions of interest and regions at risk (sensitive structures) in reliance on the images taken in the image input step. As part of the formal designation, the clinician determines the level of radiation each designated region should receive on the 2-D slices based upon the images previously obtained.
In the optimized treatment planning step, the system, based on the clinician""s formal designation, calculates the appropriate pattern, position and intensity of the radiation beam to be delivered. This is often a very time intensive process, depending on the shape complexity of the region of interest. Typically, parts of the clinician""s 2-D plan is not feasible due to shape constraints. This only becomes apparent after the system calculates what dosage each voxel in the region of interest will receive as a result of the clinician""s plan. Thus, the clinician revises his or her plan according the calculated dosages, and determines what trade-offs to make for an optimal delivery. xe2x80x9cTrade-offsxe2x80x9d involve comparing the benefit of targeting a particular voxel with knowing it will damage tissue relating to another voxel. This is an iterative process that could take several hours. Re-optimization could occur immediately after this step by repeating what was done in the optimized treatment planning step, with new information. However, it involves the same iterative process, and is generally not practical to perform at this point.
In the patient positioning/registration step, the patient is carefully positioned on the table of the radiation therapy delivery system. Then, a helical scan is preferably taken to determine the precise location of the tumor and the patient""s xe2x80x9coffsetxe2x80x9d from his/her position: the difference between the patient""s position during planning and the current position. This is preferably done in one of two ways: image fusion in which the radiotherapist superimposes the two images on a monitor, then manually or automatically adjust the planning image to get the best match; or registration in projection space in which the system calculates the best match using sinograms (the data from which a CT image is constructed), without reconstructing the images themselves. Re-optimization could occur after this step, but is generally too time consuming for practical purposes.
Delivery modification is the step in which the clinician compensates for changes in the patient""s position or the location of the tumor. Using the offset calculated in the Patient Registration step, the system recalculates the delivery pattern based on the patient""s displacement.
Delivery is the step in which the final delivery pattern is actually applied to the patient by the radiation therapy delivery system.
Delivery Verification uses a signal measured at an exit detector to verify the delivery by computing the energy fluence directed toward the patient. This information can be used to compare the current delivery with the planned delivery, as well as to reconstruct the dose. It also can shut down the unit if a delivery error is detected.
Dose Reconstruction uses the incident energy fluence delivered and a radiographic image that was obtained either before, after, or during the treatment, to compute the dose deposited to the patient (xe2x80x9creconstructedxe2x80x9d) and compared with the planned dose. This allows the physician to make an xe2x80x9capples-to-applesxe2x80x9d comparison between the actual and planned dose, and if necessary adapt the treatment plan for the next session.
In the deformable dose registration step, the clinician obtains the reconstructed dose for a series of fractions. This permits the system to calculate a cumulative dose distribution. With this information, the clinician can study the treatment delivery, modify the treatment for future fractions, and analyze patient outcomes. If there are any changes in the patient anatomy from one fraction to the next or even within a fraction (called xe2x80x9cdeformationsxe2x80x9d) they need to be taken into account when calculating the cumulative dose. Relying on anatomical, biomechanical, and region of interest information, deformable dose registration maps changes in the patient""s anatomy between each fraction. Using this information, the reconstructed dose for each fraction will be mapped back to a reference image. These mapped doses can then be added to obtain an accurate cumulative dose measurement.
When the shape of the target has changed due to internal or external influences, the planned level of radiation that each designated region receives may no longer be optimal. For example, a tumor may have grown in size since the treatment was planned, or the position or shape of surrounding sensitive structures may have changed. If the planned therapy were administered without change, a portion of the tumor would be missed, thereby diminishing the effectiveness of the treatment. Alternatively, if the tumor has decreased in size, healthy tissue would be dosed with an unnecessary amount of radiation and tissue damage would occur. Rather than doing nothing to change the dosage, the energy fluence values can be adjusted prior to delivery so that underdosed target voxels receive more radiation, and overdosed region of risk voxels receive less radiation.
The fluence adjustment is made by comparing the planned dose distribution with a newly calculated dose distribution based on current images. A radiation oncologist or the like either approves the newly calculated dose, or ascertains what voxels need fluence adjustment prior to radiation delivery. In another embodiment of the present invention, fluence adjustments are made after the delivery step. This allows the physician to immediately reapply radiation to any new regions of interest so that the patient does not have to wait until the next treatment session, which could be many days later.
The method of the present invention can be used immediately after delivery modification, acquisition of a pretreatment CT image, dose reconstruction or optimization.
The foregoing and other objects and advantages of the invention will appear from the following description. In the description references made to the accompanying drawings which form a part hereof, and in which there is shown by way of illustration, several embodiments of the invention. Such embodiments do not necessarily represent the full scope of the invention, however, and reference must be made therefore to the claims herein for interpreting the scope of the invention.